Assessment

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Entrance into System
Arrest
Psych Emergency
Emergency Room
Assessment
Domestic Violence
Family Court
Probation - Parole
Schools
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Abuse versus Addiction

• Substance Abuse is distinguished from Addiction
  by the appearance of tolerance and withdrawal,
  leading to loss of control over use.
• Substance abusers require motivation to stop.
• Addicts require treatment to stop.

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Monitoring and Treatment
In-custody Treatment
Residential Treatment
IOP Sober Living
Intensive Outpatient IOP
Addict
Re-entry Monitoring Random UDS 6 months
(Positive UDS)
Entry
Assessment
Monitoring Random UDS 6 tests/90 days
?
Discharge
Unsure
Discharge
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Epidemic

• Rapidly spreading outbreak of disease that
  affects an unexpectedly large number of people
  within a very short period.

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Prescription Drug Abuse

• Opiate pain medications
• Benzodiazepine tranquilizers
• Prescription stimulants
• (Adderall, Ritalin)
• Sleeping pills, muscle relaxants

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National Survey on Drug Use and Health Statistics
2007
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Definition of Addiction

• Compulsion loss of control
• The user cant not do it s/he is compelled to
  use.
• Compulsion is not rational and is not planned.
• Continued use despite adverse consequences
• An addict is a person who uses even though s/he
  knows it is causing problems.
• Addiction is staged based on adverse
  consequences.
• Craving daily symptom of the disease
• The user experiences intense psychological
  preoccupation with getting and using the drug.
• Craving is dysphoric, agitating and it feels
  very bad.
• Denial/hypofrontality distortion of cognition
  caused by craving
• Under the pressure of intense craving, the user
  is temporarily blinded to the risks and
  consequences of using.

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Surveillance

• A system of data collection to monitor disease
  (drug use) in the community

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Prescription Drug Surveillance Surveillance a
system of data collection for monitoring drug
use in the community

• Opiate mis-prescribing by local providers
• Diversion of prescription opiates/ doctor
  shopping
• Schoolyard sales
• School drop out rates, expulsions and suspensions
  
• Emergency room/hospital admissions
• Pharmacy thefts/Fake prescriptions
• Street sales
• Increased local availability of heroin
• Public health clinics monitoring for HIV,
  Hepatitis BC, Abscesses
• Admissions to local treatment facilities
• Jail admissions for possession, car break-ins,
  residential burglaries
• Increased appearance of opiate addicted
  prostitutes
• Data on causes of death from death certificates

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Sentinel Event

• Clusters of deaths in a community, school,
  facility, work site or other institution over a
  short period.
• Clusters of drug use in a community, school,
  facility, work site or other institution, usually
  three or more cases over a short period.

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Sentinel Events in Prescription Drug Abuse

• Overdoses in younger individuals
• DUI arrests with low BAL
• Youth falling asleep in school
• Youth stealing from parents and friends
• Increased schoolyard drug and pill sales

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National Survey on Drug Use and Health Statistics
2007
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National Survey on Drug Use and Health Statistics
2007
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Youve Got Drugs V Prescription Drug Pushers on
the Internet. National Center on Addiction and
Substance Abuse, Columbia University 2008
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Prescription Opiates

• Generic Brand Name Non Tolerant 24 hr. dose
• Codeine w/acetaminophen 500 mg
• HydrocodoneVicodin, Lortab, Norco 20mg-60 mg
• Hydromorphone Dilaudid 20 mg-60 mg
• Oxycodone Percodan, OxyContin 20 mg-60 mg
• Morphine sulfate MS Contin 30 mg-60 mg
• Fentanyl Duragesic (transdermal), Actiq 25
  mcg-50 mcg
• Tolerant Users only Tolerant 24 hr. dose
• Morphine sulfate MS Contin 60 mg-upward
• Fentanyl Duragesic (transdermal) 75 mcg-300 mcg
• Methadone Methadose 60 mg-300 mg
• Buprenorphine Suboxone, Subutex 6 mg-32 mg

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Opiate progression from pills to the needle

• Historically, untreated dependence on
  prescription opiates led to a trajectory from
• Pills ingested orally
• Pills crushed and snorted or smoked
• Heroin snorted or smoked
• Heroin used intravenously

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A 33-year follow-up of narcotics addicts

• .

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Overview of Buprenorphine Suboxone and Subutex

• Highly safe medication (acute chronic dosing).
• Primary side effects like other mu agonist
  opioids (e.g.,nausea, constipation) but may be
  less severe.
• No evidence of significant disruption in
  cognitive or psychomotor performance with
  buprenorphine maintenance.
• No evidence of organ damage with chronic dosing.
• Use of Buprenorphine in the Pharmacologic
  Management of Opioid Dependence A Curriculum of
  Physicians. (eds Strain EC, Trhumble JG, Jara
  GB) CSAT. 2001

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Prescription Tranquillizers

• Dose Equivalent To Alcohol
• (2oz liquor or 2 glasses of wine or 2 cans of
  beer)
• Alprazolam (Xanax) 0.5- 1mg
• Diazepam (Valium) 10mg
• Chlordiazepoxide (Librium) 25mg
• Clonazepam (Klonopin) 1-2mg
• Lorazepam (Ativan) 2mg
• Temazepam (Restoril) 30mg
• Butalbital (in Fiorinal) 100mg
• Carisoprodol (Soma ) 350mg
• Zolpidem (Ambien) 10 mg

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Sedative-Hypnotic Effects

• Effects
• Calm Euphoria
• Release of Inhibitions
• Sleep Inducing
• Sedation/Sleepiness
• Slurred Speech
• Unsteady gait (Ataxia)
• Confusion
• Forgetfulness
• Slows heart rate
• Decreases blood pressure
• Symptom may continue for months

• Withdrawal
• Dysphoria
• Anxiety
• Insomnia
• Sweating (Diaphoresis)
• Tremor
• Tachycardia
• Hypertension
• Hyperventilation
• Elevated temperature
• Hallucinations
• Seizures
• Delirium tremens

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Prescription Stimulants

• Adderall is a brand-name pharmaceutical
  psychostimulant composed of mixed amphetamine
  salts. Adderall is widely reported to increase
  alertness, concentration and overall cognitive
  performance while decreasing user fatigue.
• Prescription Stimulants are Schedule II drugs
  under the Controlled Substance Act for the United
  States.
• Concerta, Vyvanse, Dexedrine are similar, often
  abused, prescription psycho-stimulants.

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Medications for Stimulant Dependence

• Antidepressants (anhedonia/anergia)
• Effexor XR 150-300 mg
• Cymbalta 60 mg
• Wellbutrin XL 150-300 mg
• Desipramine 100-200 mg
• Anti-Craving Medications
• Modafinil 100-200 mg
• Methylphenidate LA 10-40 mg
• Buproprion 150-300 mg
• Concerta 18-54 mg
• Dexedrine SR 20-30 mg

• Disorders of Sleep
• Trazedone 50-300 mg
• Seroquel 25-100 mg
• Imipramine 100-200 mg
• Disorders of Thought
• Abilify 2-10 mg
• Haldol 1-2 mg Risperdal 1-3 mg

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C I M Model Treatment Causes of Craving

• E W M S
• Environmental cues (Triggers)
• immediate, catastrophic, overwhelming craving
  stimulated by people, places, things associated
  with prior drug-use experiences
• Drug Withdrawal
• inadequately treated or untreated
• Mental illness symptoms
• inadequately treated or untreated
• Stress equals craving

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Environmental Cueing Conditioned Craving

• Drug pleasure becomes associated with specific
  people, places, and things to encounter any of
  those things in the environment is to trigger
  craving for the drug. Such triggers persist for
  decades after use.

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C I M Model TreatmentComponents of Treatment

• Initiation of Abstinence Stopping Use
• Drug Detoxification Use of medications to
  control withdrawal symptoms
• Avoidance Strategies Measures to protect the
  client from environmental cues
• Schedule Establishing times for arising,
  mealtimes, and going to bed
• Mental Health Assessment and Treatment
• Relapse Prevention
• Drug Detoxification Continued use of medications
  to control withdrawal
• Avoidance Strategies Controlled re-entry to
  cue-rich environments
• Schedule Adherence to a regular daily lifestyle
• HUNGRY Three regularly spaced meals each day
• ANGRY Separate feelings of anger from losing
  control of behavior
• LONELY One positive social contact per day
  minimum
• TIRED Daily practice of sleep hygiene
• Tools Behaviors that dissipate craving
• Exercise Spiritual Practice Talk
  Peer Support Groups Counseling Having
  Fun
• Mental Health Treatment

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Community Response to MethamphetaminePregnant
and Parenting Families
Drug Treatment Outpatient 11 and group
Dependency Court
Child Protective Services Child Welfare
worker Dependency Court
Educational Interventions Parenting Class
Anger Management Class Battered Womens support
Public Health Nursing
WIC Nutritionist Nurse Practitioner
Community Support 12-Step Programs
Church/Pastoral counseling
Housing Halfway housing that accepts
children Section 8
Mental Health Treatment Medication Management
Therapy
Offender Supervision Probation Parole Jail
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REFERENCES

• --- Responsibility and choice in addiction.
  Psychiatric Services. 53(6)707-13 (2002).
• Bechara A. Decision making, impulse control and
  loss of willpower to resit drugs a
  neurocognitive perspective. Nature Neuroscience.
  81458-63 (2005)
• Dackis C, OBrien C. Neurobiology of addiction
  treatment and public policy ramifications. Nature
  Neuroscience. 8(11)1431-6 (2005).
• Nestler EJ, Malenka RC. The addicted brain.
  Scientific American.com February 9, 2004.
• Stalcup SA, Christian D, Stalcup JA, Brown M
  Galloway GP. A treatment model for craving
  identification and management. Journal of
  Psychoactive Drugs. 38235-44, 2006
• Volkow ND, Fowler JS, Wang GJ. The addicted human
  brain insights from imaging studies. The Journal
  of Clinical Investigation. 111(101444-51 (2003).
• Weinberger DR, Elvevag B, Giedd JN. The
  adolescent brain a work in progress. National
  Campaign to Prevent Teen Pregnancy. June 2005.